Sinus aspergilloma in rheumatoid arthritis before or during tumor necrosis factor-alpha antagonist therapy

Abstract

IntroductionIn 2008, the Food and Drugs Administration required manufacturers of TNFα antagonists to strengthen their warnings about the risk of serious fungal infections in patients with rheumatoid arthritis (RA). Sinus aspergilloma occurs occasionally in RA patients and can progress to invasive Aspergillus disease. The purpose of this study was to describe symptomatic sinus aspergilloma in RA patients treated with TNFα antagonists.MethodsRetrospective descriptive study of symptomatic cases of sinus aspergilloma in patients with RA followed in three French university hospitals. A systematic literature review was performed.ResultsAmong 550 RA patients treated with TNFα antagonists, six (1.1%) had symptomatic maxillary aspergilloma diagnosed by computed tomography before or during TNFα antagonist therapy. None had chronic neutropenia. Aspergilloma treatment was with surgery only in all six patients. In the literature, we found 20 reports of Aspergillus infection in patients with chronic inflammatory joint diseases (including 10 with RA). Only 5/20 patients were treated with TNFα antagonists (invasive lung aspergillosis, n = 3; intracranial aspergillosis, n = 1; and sphenoidal sinusitis, n = 1).ConclusionsOtorhinolaryngological symptoms must be evaluated before starting or switching TNFα antagonists. Routine computed tomography of the sinuses before starting or switching TNFα antagonists may deserve consideration.

Unilateral Frontal Sinus Aspergillosis: A Case Report and Review Literature

“…The patient underwent a brain CT scan for an investigation. Some authors claim that CT scan is best for diagnosing sinus aspergilloma showing sinuses involved by the presence of a hyperdense mass with bony expansions or erosion of the cranial base [4]. Although a CT scan and an MRI can reveal the diagnosis.…”

Implications of Endodontic-related Sinus Aspergillosis in a Patient Treated by Infliximab: A Case Report

“…Rheumatoid arthritis, because of its dysimmune nature (38) and the associated treatments (anti-TNF-a in particular) (10,39), notably increases the risk of infection (40).…”

“…A polycentric study from Leboime et al (39) including 550 patients treated with anti-TNF-a reported 6 cases of sinus aspergillosis (1.1%). No evolution to an invasive form of the disease can be found in this study.…”

“…A dental examination and panoramic radiography are considered necessary in this context. Leboime et al (39) suggested implementing a systematic search of sinus aspergillomas by performing a scanner before establishing biotherapy.…”

Fungal Infections in the Era of Biologic Therapies

“…The estimated incidence of aspergillosis is approximately 7 cases/100,000 persons treated [8,18]. To date, greater than 75 cases of aspergillosis have been reported in patients receiving TNFI, mostly with use of infliximab [12,[23][24][25]. A summary of cases was published by Tsiodras and colleagues, who reviewed publications from January 1966 through June 1, 2007 to determine the association of fungal infections with TNF-α blockade [12].…”